Age,12-Step Group Involvement,and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis

Abstract

The purpose of this paper is to explore the use of sobriety date as recovery start date, from the perspective of those in recovery, using a mixed methods approach. We report findings from 389 individuals who identify as being in recovery from a substance and/or alcohol use disorder concerning how they define their recovery start date. We report findings from logistic regression examining how the use of a sobriety date as a recovery start date differs across age, 12-step group engagement, and previous relapse occurrence. We complement these findings with qualitative data from focus groups discussions of how 44 individuals who identify as in recovery define what “recovery” means, how and why people choose their recovery start date, and the significance of sobriety in recovery start date definitions. About 50% (n = 182) of the quantitative sample defined their recovery start date as their date of last substance use or their first day of sobriety. Individuals who were younger, engaged in 12-step groups, and did not report a relapse had significantly greater odds of using a sobriety date as their recovery start date. Focus groups revealed nuances around sobriety date and, what for some was, a broader concept of recovery. The current findings prioritize the views of those in recovery to understand and define their own recovery start date. How those in recovery think about and define their recovery start date may have particular meaning. Research and clinical work would benefit from inquiring about recovery and sobriety dates separately.

Keywords

substance use disorder alcohol use disorder opioid use disorder recovery sobriety

What do we already know about this topic?

How does your research contribute to the field?

The purpose of this paper is to explore the use of sobriety date as recovery start date, from the perspective of those in recovery, using a mixed methods approach; we find that individuals who are younger, engaged in 12-step groups, and do not report a relapse have significantly greater odds of using a sobriety date as their recovery start date.

What are your research’s implications towards theory, practice, or policy?

This study provides initial data suggesting the importance of examining the use and impact of sobriety dates within the recovery community; research and clinical work would benefit from separately inquiring about recovery and sobriety dates to understand how best to support those in recovery.

Introduction

There is no commonly agreed upon definition of what it means to be in recovery from alcohol (AUD) or substance use disorder (SUD).^1
-3 Ashford et al⁴ summarize previous work and define recovery as “an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.” Definitions⁴ often describe recovery as “a process of change,”^5
-9 although some refer to it as a state.⁸ Most reference some aspect of recovery being self-directed or voluntary,^2,3,10 accompanied by a positive improvement in health and wellness^2,3,5,6,9,10 and, often, total abstinence from any mood-altering drugs.^2,8,9

White³ highlights the importance of including the voices of those in recovery in defining and understanding recovery, as their views may differ from those of experts or the general public. People in recovery mostly view abstinence as necessary,^1,11 although not sufficient, for recovery, noting that recovery also requires having a “new life,” and as “an ongoing process of growth, self-change, and reclaiming the self” from addiction^1,12; a minority include non-abstinence-based goals.¹³ Recent expert definitions describe recovery as “a process” through which individuals “pursue both remission from AUD and cessation from heavy drinking”¹⁴ and “improve their health and wellness, live self-directed lives, and strive to reach their full potential.”¹⁵ These definitions separate remission (ie, overcoming illness, no longer meeting criteria for a use disorder, and regaining health and social function) from being “in recovery” (which further includes positive change and growth), indicating that total abstinence is not a requirement for recovery. Public perceptions also often view recovery as a process of stopping drug or alcohol use,^1,16 but tend to more closely link recovery with total abstinence.^11,17

Over time, there has been a shift from viewing recovery as abstinence to a long-term, gradual “process of behavior change characterized by improvements in biopsychosocial functioning and purpose in life.”¹⁸ However, people in recovery often define the start of their recovery as a sobriety date when they stopped all drug or alcohol use and measure their time in recovery as the length of their total, continued sobriety. Some of this is driven by 12-step approaches (eg, Alcoholics Anonymous, Narcotics Anonymous), where different colored chips are used to symbolize milestones, such as starting/renewing a commitment to sobriety, 24 h of sobriety, 30 days of sobriety and so on. Many meetings start with statements such as, “I’ve been sober for X days. . .” Viewing one’s own recovery as dependent on abstinence or sobriety as opposed to a process, that may or may not include periods of substance use, may carry significant meaning for the individual.

Definitions of recovery start date, and the reliance on sobriety as a key element in choosing one’s recovery start date, are likely to differ across individuals. Four prime factors may relate to recovery start date definition differences: The first factor is age, as young adults with SUD may more strongly emphasize the ideas of “growing up” and living a “normal life not defined by substance use” rather than total abstinence or sobriety.^19,20 The second factor is time in recovery, as one’s perspective about recovery may become more process-oriented as recovery enters longer and more stable phases, whereas those in early recovery may rely more on sobriety date markers.^21
-23 The third factor is engagement in 12-step groups, as these groups may make it more likely for one to utilize sobriety as a marker of recovery, given that 12-step groups often emphasize abstinence-only approaches.²⁴ The fourth factor is whether the person endorses having previously had a relapse; those who view recovery as abstinence may “reset” their recovery start date after a relapse, whereas those who do not equate recovery with abstinence may include a longer time period of recovery that encompasses relapse episodes. Previous research has not examined these factors empirically.

The purpose of this paper is to explore the use of a sobriety date as a recovery start date from the perspective of those who are in recovery, using a mixed methods approach. We report findings from individuals who identify as being in recovery from SUD/AUD concerning how they define their recovery start date. We examine how the use of “sobriety date” as a recovery start date may differ across age, time in recovery, 12-step engagement, and reported history of relapse. We complement these findings with qualitative data from focus groups of those who identify as in recovery concerning what the word “recovery” means, how and why people choose their recovery start date, and the significance of sobriety in recovery start date definitions.

Methods

Participants

All study procedures were approved by the IndianaUniversity Institutional Review Board. Participants were recruited through study fliers, interest forms, e-mails, social media posts, and word-of-mouth through 2 addiction treatment centers. Individuals contacted study personnel, who conducted a phone screening, scheduled individuals for sessions, and completed informed consent procedures.

Measures and Procedures

Sample 1 participants completed an in-person or phone interview and a paper or online survey and were compensated $40. Participants self-reported their date of birth, race, ethnicity, sex, gender, income, education, substances of use, what they use as their recovery start date, the reason for choosing their recovery start date, whether they are engaged in 12-step groups, and whether they had a previous relapse (Supplemental Table 1). Sample 2 participants completed a demographics questionnaire (age, gender, race, ethnicity, income, education, recovery start date, and diagnosis; Supplemental Table 2) and participated in a two-hour focus group consisting of 4 to 10 individuals led by 2 to 3 researchers and were compensated $40. Approximately 14 to 20 questions were presented, including questions concerning the definition and meaning of recovery (Supplemental Table 3). The facilitator presented open-ended, structured interview questions and participants discussed their responses as a group, with occasional facilitator probing.

Quantitative data were cleaned and study variables calculated. Reasons for choosing their recovery start date were coded by one author, with multiple themes reflected. Differences in the use of a sobriety date across age, time in recovery, 12-step engagement, and reported history of relapse were examined using Chi-square tests (for categorical variables) or t-tests (for continuous variables). The Box-Tidwell²⁵ procedure was performed to assess for linearity in the relationship between the continuous independent variables (age, time in recovery) and the logit of the dependent variable (sobriety date as recovery start date). Bonferroni correction was applied, resulting in acceptable significance (P < .0125), thus rendering logistic regression an appropriate method of analysis. Logistic regression was used to examine how characteristics associated with the likelihood of using a sobriety date, controlling for gender (dummy-coded 0 = male, 1 = not male) and race (dummy-coded 0 = White, 1 = not White).

For qualitative data, we utilized a grounded, inductive approach.²⁶ NVivo automated transcription produced full focus group transcripts, which were edited for correctness, de-identification, and formatting purposes.²⁷ We auto-coded transcripts by question and identified initial themes informed by emergent patterns in the data.²⁸ Two coders read and coded all transcripts using the initial descriptive codebook; suggested additions were made via the NVivo memo system²⁷ and the codebook was appended. NVivo’s coding comparison and intercoder reliability functions identified discrepancies (between 87% and 100% agreement), which were discussed to reach consensus. In member-check follow-up interviews²⁹ with 16 participants, we used a synthesized member check approach,³⁰ shared our interpretations of the data, and asked participants to assess whether the interpretations resonated with their own perceptions and understanding of the conversations that occurred within the focus groups.

Results

Sample Characteristics (Table 1)

Table 1.

Sample Characteristics.

	Sample 1				Sample 2
	n = 389^a				n = 44
	n	%	Mean	SD	n	%	Mean	SD
Age			(n = 376)				(n = 38)
			41.49	11.01			40.58	12.22
Gender	(n = 378)				(n = 44)
Male	196	51.85			23	52.27
Female	178	47.09			21	47.73
Nonbinary/third gender	1	0.26
Prefer to self-describe	1	0.26
Prefer not to say	2	0.53
Race	(n = 378)				(n = 44)
White	322	85.19			30	68.18
Black	37	9.79			12	27.27
American Indian or Alaskan Native	2	0.53			2	4.55
Native Hawaiian or Other Pacific Islander	1	0.26
More than one race	13	3.44
Unknown or not reported	3	0.79
Ethnicity	(n = 285)				(n = 36)
Hispanic or Latino	9	3.16			1	2.78
Non-Hispanic or Latino	267	93.68			33	91.67
Unknown or not reported	9	3.16			2	5.56
Total combined family income	(n = 324)				(n = 44)
<$25 000	96	29.63			17	38.64
$25 000-$50,000	84	25.93			8	18.18
$50 000-$75,000	40	12.35			4	9.09
$75 000-$100 000	28	8.64			0	0.00
$100 000-$150 000	27	8.33			1	2.27
more than $150 000	15	4.63			2	4.55
Don’t know/not sure	21	6.48			7	15.91
Decline to respond	13	4.01			5	11.36
Highest degree earned	(n = 324)				(n = 44)
High school diploma or equivalence (GED)	145	44.75			26	59.09
Associate degree or vocational degree/license	53	16.36			7	15.91
Bachelor’s degree	70	21.60			3	6.82
Master’s degree	19	5.86			1	2.27
Doctorate, professional (MD, JD, DDS)	6	1.85			1	2.27
Other	31	9.56			6	13.64
Recovery duration
<1 year					20	45.45
>3 years					24	54.55
Diagnosis	(n = 377)				(n = 44)
OUD	253	67.11			44	100.00
SUD	124	32.89
12-step group engagement	(n = 315)
Yes	245	77.80
No	70	22.20
Relapse^b	(n = 376)
Yes	79	21.01
No	297	78.99

Sample size is reduced for some characteristics due to non-response on items.

Response to the question: “Have you had any relapses during your recovery?”

Sample 1 included 389 adults (51.85% Male, 85.19% White, mean age = 41.49 (SD = 11.01; Range 19-77)) who self-identified as in recovery from SUD and/or AUD. Sample 2 included 44 adults (52.27% Male, 68.18% White, mean age = 40.58 (SD = 12.22; Range 22-69)) who self-identified as in recovery from Opioid Use Disorder (OUD. In Sample 1, 62.98% reported being engaged in 12-step groups and 21.01% reported having had a previous relapse. The mean time in recovery was 2.92 (SD = 5.43) years. In Sample 2, 45.45% reported being in recovery less than 1 year, while 54.55% reported being in recovery for more than 3 years.

Recovery Start Date Definition Themes–Quantitative Findings

In Sample 1, 93.32% of individuals (n = 363) reported a recovery start date. Definitions included date of last use/first day of sobriety (50.14%), started treatment (39.67%), self-commitment to put effort into recovery (13.50%), negative life events (11.57%), entered jail/legal issues (8.54%), physical/mental health issues (4.96%), admitted that they had a problem (4.41%), left treatment/ended medication (2.48%), or started a new life (2.48%).

Differences in Recovery Start Date as Sobriety Date Across Characteristics–Quantitative Findings

Group comparison analyses indicated that participants who used a sobriety date as their recovery start date were on average younger (t = 2.82, P = .01), more likely to be engaged in 12-step groups (χ² = 6.70, P = .01), and less likely to report having had a relapse (χ² = 16.92, P < .001), than those who did not use a sobriety date as their recovery start date. Time in recovery was not associated with odds of using a sobriety date (t = −0.73, P = .47).

Logistic regression analyses controlling for gender and race found similar results (Table 2): each additional year increase in age was associated with a 2.2% decrease in odds of using a sobriety date (Odd’s Ratio (OR) = 0.98, P = .03); 12-step group engagement was associated with an 85% increase in odds of using a sobriety date (OR = 1.85, P = .04); and having had at least 1 relapse was associated with a 69% decrease in odds of using a sobriety date (OR = 0.31, P < .001). Time in recovery was not associated with odds of using a sobriety date (OR = 1.01, P = .68).

Table 2.

Logistic Regression Results.

	Model 1					Model 2					Model 3
	β	SE	P-value	Exp(β)	95% CI	β	SE	P-value	Exp(β)	95% CI	β	SE	P-value	Exp(β)	95% CI
Gender	.18	0.21	.38	1.20	0.80-1.82	.52	0.24	.03	1.69	1.06-2.69	.40	0.22	.07	1.49	0.97-2.29
Race	−.51	0.31	.10	.60	0.33-1.11	−.57	0.33	.09	.57	0.30-1.09	−.77	0.31	.01	0.46	0.25-0.86
Age	−.02	0.01	.03	.98	0.96-1.0
12-Step						.61	0.29	.04	1.85	1.04-3.28
Relapse											−1.17	0.28	<.001	0.31	0.18-0.54
Constant	.81	0.44	.07	2.25		−.58	0.30	.05	.56		.12	0.16	.47	1.12
	n =376					n = 306					n = 366
	Nagelkerke R² = .04					Nagelkerke R² = .05					Nagelkerke R² = .09
	β² = 11.31 (3), P = .01					β² = 12.53 (3), P = .006					β² = 26.17 (3), P < .001

Gender was not significantly related with odds of using a sobriety date (OR = 1.49, P = .07). Race was significantly associated with using a sobriety date, such that identifying as not White (vs White) was associated with lower odds of using a sobriety date (OR = 0.46, P = .01).

Recovery Start Date as Sobriety Date–Qualitative Findings (Table 3)

Table 3.

Qualitative Findings

Recovery date is sobriety date (12-step commonly mentioned)

“My recovery date today is April 15 2005 and I’ve had numerous dates before then because no this was something that definitely wasn’t easy.”—Rachel, Age 53“I think you start a recovery as soon as you stop using drugs regardless of how hard you’re working at it or what have you.”—Bennett“As far as recovery is concerned if I relapse, yea, I’d be starting over but I already have all the tools and all the knowledge and everything I’ve learned you know. Like Matthew I’ve done the steps and eight and nine was the bitch for me. You know made a list of all the persons I had hurt you know. And then I had to go and make direct amends. A lot of them had passed away and write a letter to them and then just tear it up you know. Some people go to the cemetery and talk to them you know which I didn’t. But if I relapse it’s starting over.”—Paul, Age 63“I walked into Fairbanks seven years ago and haven’t used since. . ..I tried everything. And I’ve been court ordered my first court ordered recovery was at Central State Mental Hospital back in ‘98. And yeah, so I tried several different ways to stop. But yeah, I didn’t even know. I did everything to try to prove I wasn’t a drug addict. And the whole time I was so yeah, I tried to stop multiple times. . .that wasn’t recovery.”—Austin, Age 63“That was the last time I used. That’s when I came into the rooms April 15^th 2009.”—Matthew, Age 54“My sobriety date is October 20th of 2018. I got arrested on the 17th of October and even though I got out the same day, or the next day, I drank one more day. And then I was completely sober on the 20th. That’s why I use that as my date.”—Catherine, Age 30“October 5th. And the reason why I use that date is because that was the date that I turn myself in and that was the date I started my recovery when I was incarcerated for nine months and then it’s just been. You know. Ever since I haven’t gone back to using anything like that.”—Audrey, Age 61“Mine’s June 6, 2019. It’s the day I went to treatment. I went to treatment on the fifth, but I was high, so I just counted that day out. —Trevor, no age provided“[B]ut the 12-step program which is the only thing that I know that works for people to recover, they all include only the first step mentions the drug. The other eleven steps have nothing to do with the drug. It’s about the person, about living. So for a personal recovery, I don’t care what it’s from, they do the same deal. It helps– you got to quit using first. . . The recovery though, recovery is recovery. And that’s the other 11 steps of whatever 12 step program that you’re working once you stop using in the first thing. . .. My recovery coach training differs from what I believe. Recovery coach training says that a person’s in recovery when they say they are. They say I’ve only smoked five joints a week instead of 20. But my sponsorship family and the way I live my program says I don’t do any of that stuff. There’s no, that question I don’t know that you’re ever going to get an answer because you know I mean if I’m working as a Recovery Coach I can’t apply what I believe in that job – it’s not the same."—Russell, Age 69“Relapse is absence of recovery as far as the way I look at it. I mean you hear from day one that relapse is part of recovery. But I fully believe that the reason that people relapse is either they forgot the pain or they’re not working their program, which means they’re not actually acting in working.”—Austin, Age 61“Being in recovery was facing responsibility. . .because I did not want to stop getting high. . ..February 3, 2015. . .I overdosed and, in the ambulance, they used Naloxone, I sat straight up and said, ‘I need help.’ I knew I couldn’t do it alone.”—Travis, Age 46Uses sobriety date, but recognizes that relapses may be part of recovery: “June 24th. But I went to detox June 10. And I smoked pot after I got out detox and I was going to claim that date because I didn’t think pot was a big deal. But now I do. So it’s June 24th. . .. Each time I feel like I relapse I learn from it. And even though I regressed I still learned something like if I learn something from it then I think it could be considered recovery.”—Cody, Age 40

Recovery date precedes most recent sobriety date; recovery has included (or may include) episodes of use

“My clean date is March the 16th 2018 and that’s the last date that I used any mind-altering substance, but I’ve been at this for many, many, many years so like December 3rd of 1994. But I have a clean date, but I’ve been around the recovery world for a long time.” –Russell, Age 69“So the day that I started in recovery was the day I was arrested April 20th 2002. So that was the first thing that ever broke the chain of opiate addiction for me but my sobriety date or clean date whichever program you’re in is February 18th 2018 because that’s the day after, the last day that I drank alcohol.”– George, Age 50“Yeah, I had setbacks. It was just part of it. I mean I look at it like I was losing before and then I go into recovery, and you relapse. Look at what you’re losing all over again. I just think it’s part of it.” –Kurtis, Age 46“OK, well then, when I first started recovery was 10/15/15. Had a lot of relapses since then clearly because my last sobriety date is 03/22/19. I did a therapeutic program that was like 10 months long very intense and that started in 11/2015. So yeah.” –Heather, Age 31“[W]e use a workbook and it’s WRAP stands for wellness recovery action plan where we do talk about trauma and we do we dig a little deeper because our philosophy is that most of us are trauma kids. You know what I mean. And so with the 12 step programs you deal with sobriety and how to stop using it and learning how to live your life and serve others which is what I think everybody should live that way. When we come full circle. But it doesn’t deal with anything deeper than that. And to me for me my drug addiction isn’t just about this obsession that uncontrollable obsession to use. No, it has everything to do with “I suffered through some shit”. You know what I mean. So. And that until I was able to kind of deal with some of that stuff, and then learn how to cope in other ways, was I able to be more successful.” –Audrey, Age 61“It depends on how you define your recovery. If I stay sober until the day, I die from the point of my current recovery which is May 21st then without a doubt my past relapses were part of getting me to this. So, do you measure it as the last time I used? I don’t know how you actually measure or define recovery, ya know what I mean?”—Abel, no age provided

Focus group discussions highlighted the importance of 12-step group engagement and relapse for those who define their recovery start date as a sobriety date; there was no pattern across age (all are middle adulthood) or time in recovery (months to years). Participation in 12-step groups was associated with a focus on a specific sobriety date as a necessary factor for recovery; however, narratives also reflected longer-term recovery journeys that included relapses and multiple efforts at sobriety. Individuals discussed having “numerous dates before” and that any prior attempt to quit using “wasn’t recovery.” One individual noted that “Recovery is progressive. Experience is invaluable. Does relapse count [as recovery]? No. Experience of relapse helps you. Yes! It’s the experience of that guilt that helps you.” Others went on to agree but pointed out that they had concerns that saying “relapse is part of recovery” is a “free ticket” that makes it harder for those in recovery to stay focused on sobriety and easier to return to use. For them, “relapse is not a part of recovery, it’s a part of your story.”

For those who did not endorse using a sobriety date, relapse and 12-step engagement were also discussed as key factors influencing how one viewed their recovery start date, but they described recovery more as a shift in mindset and a broader process and less as about abstinence. For many who endorsed this perspective, relapse had been part of their progressive recovery journey, and many described separate recovery and sobriety dates. For these individuals, abstinence was still a central part of how they define their recovery; however, it was one small piece of recovery. Importantly, they endorsed the idea that relapse did not have to destroy the recovery journey and that the experience of relapse may help a person move further down the road to a life focused on recovery. One person noted that in their 12-step group they had a saying that “clean time doesn’t equal recovery because you can be abstinent. . .[but] there’s no recovery to it,” highlighting the separation of recovery and sobriety dates and also that there were differences in how 12-step groups approached these dates.

Discussion

Despite growing support for the idea that recovery is a process that may or may not include total abstinence, approximately half of our quantitative sample reported using a sobriety date as their recovery start date. The theme that recovery requires sobriety was also frequent in our focus groups. This report directly examined factors associated with the use of a sobriety date as a recovery start date, catalyzing future research and having potential applications for clinical settings.

Although we expected sobriety date to be less salient for younger individuals,^19,20 we found the opposite. Some existing literature^31
-33 suggests older adults have better recovery outcomes, which may indicate less of a need to emphasize a sobriety date and a stronger focus on the entirety of their recovery process. The current pattern could reflect that understanding recovery as separate from sobriety and as a longer process of change may come over time or it could reflect generational differences. Future work should examine age effects across the lifespan, including adolescents. Prospective work should examine whether recovery views vary by generation and whether they are stable or change over time. Based on prior work^21
-23 and the idea that individuals would “reset” their recovery start date after relapses, we expected to find shorter time in recovery to be associated with greater odds of using a sobriety date, we found no relationship across our quantitative and qualitative data. This suggests that views about sobriety might not change throughout time in recovery. Early recovery often focuses on getting sober (eg, completing detoxification). Later recovery also emphasizes sobriety, but also other recovery-related processes and growth. Thus, our findings support the idea that recovery at all stages emphasizes sobriety; however, additional layers might be added in later recovery stages.

Affiliation with 12-step groups was associated with using a sobriety date as recovery start date in our quantitative findings, consistent with prior work.²⁴ Twelve-step involvement shaped how our focus group participants defined and discussed recovery, and the most common definition was that recovery requires sobriety. However, participants in our focus groups had differing views on the 12-step model’s reliance on sobriety. One participant stated that, “One thing I don’t like about 12-step recovery is when you relapse. And you have to start counting all over. It almost made me, and I did throw the towel in a couple times.” Another participant experienced support in their 12-step program when they discussed their relapse, noting that “that’s why I liked AA because before when I relapsed my family would just, I felt like, beat me down into the dirt where I wouldn’t want to come out. So, I keep using and using and using just I felt so guilty. But when I relapsed at the beginning of when I first went to AA everybody was so wonderful and I just keep coming back you come back, and you know just keep doing this and you’ve got it. And so, supporting. So that to me has been one of the helpful things.” The way 12-step programs conceptualize abstinence and approach relapse may impact the way individuals in the group process their own relapse experience and recovery journey, which would be a prime next research question to test.

As expected, use of sobriety date was associated with fewer reported relapses in our quantitative findings, which may indicate that individuals who use a sobriety date reset their date after a relapse, but that those who do not rely on a sobriety date do not. Our focus group data supported this view, with some individuals reporting the use of separate recovery and sobriety dates, or the experience of resetting their recovery start date after a relapse. However, the argument for a broader definition of recovery with room for relapse was in the minority in most groups. Use of a sobriety date may differentially impact individuals who have experienced a relapse. On one hand, using a sobriety date may serve as an objective behavior marker of recovery—ceasing substance use—and may serve as a “clean start” for people to recommit to recovery after a relapse. On the other hand, defining recovery from an abstinence view alone does not account for the time people spend in recovery prior to relapse, fails to represent the multidimensional nature of recovery,²⁰ and may be de-motivating for individuals who feel that they must start over again on their recovery journey if they are no longer sober. Relapse is frequent in recovery^34
-36 and is associated with guilt and shame,³⁷ which may, as one of our focus group participants noted, “keep [someone] from coming back [to recovery] for a long time.” Resetting one’s date after a relapse may undervalue the prior skills, efforts, and successes of recovery; as one participant noted, “as far as recovery is concerned if I relapse, yea, I’d be starting over but I already have all the tools and all the knowledge and everything I’ve learned you know.” More work is needed to better understand how the use of a sobriety date may serve or impede recovery.

More generally, this study suggests that when asking for one’s recovery start date, it is prudent to ask both about a general date when one entered recovery, as well as when they last used substances, as these dates may differ. From a research perspective, if individuals are using different dates, it affects the quality and accuracy of the data; for example, given 2 people with similar recovery journeys, one who uses a sobriety date may underreport their time in recovery and number of relapses relative to another who does not use a sobriety date, which introduces systematic error in the measurement, impeding understanding of long-term recovery trajectories. From a clinical perspective, these different conceptualizations may have different meanings and implications for treatment planning; for example, if a client reports no relapses, but relapsed in the past and reset their recovery start date, relapse prevention may be necessary, but omitted, from their treatment plan. Fuller understanding of how individuals think about and define their recovery start and journey is key for understanding how best to support those in recovery, both through research and in clinical applications. We propose that studying recovery using both quantitative and qualitative data allow us to understand the nature of the differences and the implications for those in recovery.

We had very few participants in the current study who did not use a recovery start date; more work is needed to better understand what leads individuals to not use a date and what the implications are for recovery. Some individuals noted that they did not have a recovery start date because they were using medications for OUD (eg, methadone, buprenorphine, naltrexone), which meant that they were not “truly abstinent.” Such views may impede the use of these medications and impact stigma and treatment of individuals in recovery.³⁸

This study provides initial data suggesting the importance of examining the use and impact of sobriety dates within the recovery community. The current study was conducted during the opioid epidemic in the United States; as individuals from this cohort transition to later stages of recovery, the field may need to revise established and long-held views of recovery. The findings of the current work should be understood within study limitations, including the cross-sectional, self-selected, and self-report nature of the data, which limits causality conclusions, and the relative homogeneity of the samples (excluded adolescents; mostly non-Hispanic White, cisgender males/females; most engaged in 12-step groups without relapses), which may limit generalizability. Selection bias³⁹ may also limit external validity of findings, which could be addressed in future statistical modeling.⁴⁰ Future work should explicitly inquire about differences between recovery and sobriety dates in a prospective, more diverse sample in order to overcome these limitations. Additional factors, including prior treatment experiences²² and comorbid psychiatric disorders,⁴¹ may also affect recovery start date definitions and should be studied in future work. The current findings help us better understand how those in recovery think about the journey of recovery and the place of sobriety in the recovery process.

Supplemental Material

sj-docx-1-inq-10.1177_00469580231220476 – Supplemental material for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis

Supplemental material, sj-docx-1-inq-10.1177_00469580231220476 for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis by Melissa A. Cyders, Melissa Fry, Taylor Fox, Katherine Shircliff, Molly Jacobs and Hannah Scott in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

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Supplemental material, sj-docx-2-inq-10.1177_00469580231220476 for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis by Melissa A. Cyders, Melissa Fry, Taylor Fox, Katherine Shircliff, Molly Jacobs and Hannah Scott in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

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Supplemental material, sj-docx-3-inq-10.1177_00469580231220476 for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis by Melissa A. Cyders, Melissa Fry, Taylor Fox, Katherine Shircliff, Molly Jacobs and Hannah Scott in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

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Supplemental material, sj-xls-4-inq-10.1177_00469580231220476 for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis by Melissa A. Cyders, Melissa Fry, Taylor Fox, Katherine Shircliff, Molly Jacobs and Hannah Scott in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Research Data

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Supplemental material, sj-xls-5-inq-10.1177_00469580231220476 for Age, 12-Step Group Involvement, and Relapse Affect Use of Sobriety Date as Recovery Start Date: A Mixed Methods Analysis by Melissa A. Cyders, Melissa Fry, Taylor Fox, Katherine Shircliff, Molly Jacobs and Hannah Scott in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Footnotes

Acknowledgements

The authors would like to acknowledge Misty Kannapel Gilbert, Mary Jo Rattermann, and Kevin Ladd for their work on the larger parent grant. The authors would like acknowledge Mariah Benham, Tessa Duncan, Melissa Liu, and Christiana Prestiagiacomo for their contributions to this project.

Author Contributions

KS and TF conceptualized initial ideas for this report. MAC and MF refined the questions and focus of the report, led data analysis, and contributed to writing and editing of the manuscript. MJ and HS contributed to data coding and analysis. TF contributed to writing of the manuscript.

Data Accessibility Statement

The data that support the findings of this study are available in .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Indiana University Addictions Grand Challenge program.

Ethics and Consent Statement

All study procedures were reviewed and approved by the Indiana University Institutional Review Board. All participants completed informed consent prior to participating in the study.

ORCID iDs

Melissa A. Cyders

Katherine Shircliff

Supplemental Material

Supplemental material for this article is available online.

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